Blood Donor Form

Specialty: Nurse **Blood Donor Form** **Date:** 1 November 2024 **Donor Information:** * **Full Name:** [Sarah Williams] * **Date of Birth:** [15/03/1990] * **Gender:** [Female] * **Address:** [Flat 4, 12 High Street, Anytown, AB1 2CD] * **Contact Number:** [07700 900123] * **Email Address:** [sarah.williams@example.com] * **Occupation:** [Marketing Manager] **Consent and Eligibility:** * **I confirm that I have read and understood the information provided regarding blood donation:** [Yes] * **I confirm that I meet the basic eligibility criteria for blood donation:** [Yes] * **I agree to provide accurate and truthful information regarding my health and lifestyle:** [Yes] * **I understand that my blood will be tested for infectious diseases and other relevant markers:** [Yes] * **I consent to my donated blood being used for transfusion, research, or other medical purposes as deemed appropriate by the blood service:** [Yes] **Medical History Questionnaire:** * **Have you ever received a blood transfusion?** [No] * **Have you travelled outside of the UK in the last 12 months?** [Yes] * **If yes, please specify countries and dates:** [Spain (01/07/2024 - 15/07/2024)] * **Have you had any tattoos or body piercings in the last 4 months?** [No] * **Have you had any major surgery in the last 6 months?** [No] * **Are you currently taking any medications (including over-the-counter or herbal remedies)?** [Yes] * **If yes, please list:** [Multivitamin daily] * **Have you ever been diagnosed with or treated for any of the following conditions?** (Select all that apply) * [Hepatitis: No] * [HIV/AIDS: No] * [Malaria: No] * [Cancer: No] * [Heart Disease: No] * [Diabetes: No] * [Epilepsy: No] * [Asthma: Yes] * [Other (please specify): None] * **Are you currently pregnant or have you been pregnant in the last 6 months?** [No] * **Have you ever injected recreational drugs?** [No] * **Have you had any unexplained fever, night sweats, or significant weight loss in the last 3 months?** [No] **Declaration and Signature:** * **I declare that all the information I have provided is true and complete to the best of my knowledge and belief.** [Yes] * **Donor Signature:** [Electronic Signature of Sarah Williams] * **Date:** [1 November 2024] **Staff Use Only:** * **Blood Pressure:** [120/78 mmHg] * **Pulse Rate:** [72 bpm] * **Haemoglobin Level:** [13.8 g/dL] * **Temperature:** [36.7 °C] * **Weight:** [68 kg] * **Donor ID:** [SW900315] * **Phlebotomist Name:** [Nurse Emily Green] * **Date and Time of Donation:** [1 November 2024, 10:30 AM] * **Notes/Observations:** [Donor appeared calm and well-hydrated. Venepuncture performed without complications. Informed donor about post-donation care.]